RESEARCH ARTICLE Open Access

Ultrasound Guided Needle Aspiration versusSurgical Drainage in the management of breastabscesses: a Ugandan experienceAlphonce B Chandika1*, Anthony M Gakwaya2†, Elsie Kiguli-Malwadde3† and Phillipo L Chalya1†

Abstract

Background: Despite breast abscess becoming less common in developed countries, it has remained one of theleading causes of morbidity in women in developing countries. A randomized controlled trial was conducted atMulago hospital complex in Kampala Uganda to establish whether ultrasound guided needle aspiration is afeasible alternative treatment option for breast abscesses.

Results: A total of 65 females with breast abscess were analyzed, of these 33 patients were randomized into theultrasound guided needle aspiration and 32 patients in the Incision and drainage arm. The mean age was 23.12,most of them were lactating (66.2%), primipararous (44.6%) with peripheral abscesses (73.8%) located in the upperlateral quadrant (56%).The mean breast size was 3.49 cm. The two groups were comparably in demographiccharacteristic and breast abscess size. Survival analysis showed no difference in breast abscess healing ratebetween the two groups (Log rank 0.24 df 1 and P = 0.63). Incision and drainage was found to be more costlythan ultrasound guided aspiration (cost effective ratio of 2.85).

Conclusion: Ultrasound guided needle aspiration is therefore a feasible and cost effective treatment option forboth lactating and non lactating breast abscesses with a diameter up to 5 cm by ultrasound in an immunecompetent patient

Keywords: Breast abscess, Ultrasound guided needle aspiration, Surgical drainage, Uganda

BackgroundBreast abscess is a common cause of morbidity inwomen. While they are less common in developedcountries as a result of improved maternal hygiene,nutrition, standard of living and early administration ofantibiotics, breast abscess remain a problem amongwomen in developing countries [1]. The treatment ofbreast abscesses poses a difficult clinical problem [2].Traditionally, management of breast abscess involvesincision and drainage; however this is associated withneed for general anesthesia, prolonged healing time, reg-ular dressing, difficulty in breast feeding, and possibleunsatisfactory cosmetic outcome [3]. Even with theaggressive approach of incision and drainage combined

with use of antibiotics, breast abscess recurrence rate isreported to be between 10 and 38% [2]. Breast abscessescan be treated by repeated needle aspiration with orwithout ultrasound guidance [4-6]. Ultrasound has beenshown to be useful in diagnosis of breast abscesses,guiding needle placement during aspiration and alsoenables visualization of multiple abscess loculation andthus useful in needle aspiration of breast abscesses [7].This procedure has been used successful and is asso-ciated with less recurrence, excellent cosmetic resultand has less costs [8].Incision and drainage is still the most common mode

of treatment for breast abscesses in Uganda. There is nodata to compare the outcome of breast abscess treat-ment when using ultrasound guided needle aspirationversus surgical incision and drainage. The aim of thisstudy was to establish whether ultrasound guided needle

* Correspondence: achandika2001@yahoo.com† Contributed equally1Department of Surgery, Weil Bugando University College of Health Sciences,Mwanza, TanzaniaFull list of author information is available at the end of the article

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© 2011 Chandika et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.

aspiration is a feasible alternative treatment option forbreast abscesses in Mulago hospital.

MethodsStudy design and settingThis was a randomized controlled clinical trial with noblinding done between October 2006 and March 2007.The study was a hospital based which was conducted inMulago hospital complex which is in Kampala city witha population of about 1.2 M people. Mulago is aNational referral and teaching hospital in Uganda, it hasbed capacity 1500.The study was conducted in the Acci-dent and Emergency (A & E) department and breastoutpatient clinic.

Study subjectsThe study included all female patients aged 14 andabove who presented to A&E department and BreastClinic with breast abscess with a diameter of up to amaximum of 5 cm by ultrasound. Patients with recur-rent or chronic breast abscess and those with necroticskin overlying the abscess or abscess already drainingwere excluded from the study. Patients with clinical fea-tures of immune suppression (WHO clinical stage IIIand IV) and those known to be allergic to penicillinantibiotics were also excluded.Recruitment of patients was carried out in the Acci-

dent and Emergency department, and Breast OutpatientClinic. Patients who met the inclusion criteria wereenrolled into the study. Clinical diagnosis was madebasing on the presence of breast pain, swelling, ± feverand presence of a fluctuant tender breast swelling. Thepatients diagnosed clinically were subjected to ultra-sound scan (high frequency linear transducer of 7.5MHZ) in the radiology department. The diagnosis wasconfirmed sonographically by the presence of a thickwalled echo complex mass, predominantly cystic withinternal echoes and septations. The size of the abscesswas estimated.In this study, healing was defined as achieving breast

abscess resolution. Breast abscesses resolution wasdefined as clinically no breast tenderness, swelling orwound at the previous site of the abscess and sonogra-phically complete absence of fluid collection, normalbreast glandular and fibro fat tissue with no edema

RandomizationPatients were randomized to either incision and drai-nage or needle aspiration arm using computer-generatednumbers. A computer program (random generator num-ber, Microsoft excel version 5:0) was used to generaterandom number list. Patients were assigned to eitherneedle aspiration (A) or incision and drainage (B).Theprincipal investigator randomized patients to either A or

B as they presented at the Accident and Emergencydepartment. There was no blinding.

Treatment procedure and follow upIncision and drainagePatients in the incision and drainage arm were admittedin the Emergency ward and prepared for surgery undergeneral anesthesia in casualty theatre by the principalinvestigator. In the operation theatre with the patientpositioned supine, the breast was swabbed using Chlor-hexidine- Cetrimide (Cetrimide 15% w/v, Chlorhexine1.5%w/v Isopropylalcohol4%w/v) 35 mls in 1 L of water.A skin depth incision was made at the area of maximumfluctuation along skin lines and a sinus forceps used toreach the abscess cavity. Initial pus was swabbed with asterile pus swab which was transported for Culture andsensitivity. The pus was then evacuated and loculi bro-ken down digitally, the wound was packed with sterilegauze. After recovery, the patient was taken back toemergency ward.Post operatively the patient was put on analgesics and

antibiotics, Diclofenac 75 mg i/m stat, then 50 mg orallyfor 3 days and Cloxacillin 500 mg 8hry for 10 daysrespectively. The patient was discharged home the nextmorning to undergo daily wound dressing at a nearbyclinic until the wound heals. Patients whose culture andsensitivity results showed resistance to Cloxacillin wereexcluded from the study and the antibiotic treatmentchanged accordingly.

Ultrasound guided needle aspirationPatients under the needle aspiration arm were managedin the department of Radiology Ultrasound room as out-patient cases. Under aseptic condition, a small area ofskin adjacent to the abscess was anaesthetized by 1%Lignocaine through a 23 G needle. Aspiration was doneunder ultrasound guidance using a 16 G needle and a20 mls syringe. Initial aspirated pus was sent for cultureand sensitivity. Aspiration was done until there was nosignificant residual pus. After the procedure the patientwas discharged on antibiotics and analgesics, Cloxacillin500 mg orally 8hry for 10 days and Diclofenac 75 mg i/m stat then 50 mg orally 8hry for 3 days respectively.Similarly patients whose culture and sensitivity resultsshowed resistance to Cloxacillin were excluded from thestudy and the antibiotic treatment changed accordingly.In order to minimize non- compliance to treatment in

both arms, drugs were provided by the principal investi-gator to the patients who could not afford buying thedrugs. Patients were required to come back with thepacks of drugs during follow up visits to countercheckwhether the patients had taken the drugs. In both arms,lactating patients were advised to resume breast-feedingon both breasts as soon as possible as they could

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tolerate the pain as the baby breast feed. The patient’sfollow up was done at the OPD by the principal investi-gator on day 7, day 14 and 30 days. At every follow up,clinical assessment of symptoms and signs was done toassess resolution of the abscess.Ultrasound scan was done to assess radiological reso-

lution of the abscess which was defined as completeabsence of fluid collection, normal breast glandular andfibro fatty tissues without edema. In situation where theabscess persisted in case of ultrasound guided needleaspiration, re-aspiration was to be done on day 7, if itstill persisted on day 14 it was considered treatment fail-ure and hence converted to the traditional incision anddrainage.Breast abscess recurrence and acceptance were

assessed at the last visit (day 30). Patients who had notachieved complete resolution of the breast abscess atthe end of the study period were referred to the Breastoutpatient clinic for further follow up.

Cost estimationAll costs were done in Ugandan shillings. Costs incurredby the patients and they included; cost for antibiotics,analgesics, syringes (20 cc) and cannulas (FG 16) usedduring U.S.S guided aspiration. These were estimatedbasing on open market price obtained in the local phar-macies. Costs for lodging, professional fee, surgery,anesthesia, amenities, sundries, doctor in care fee andhealth care fee were estimated basing on the Mulagohospital private patients’ charges for the year 2007. Costfor ultrasound guided aspiration was valued basing onthe charges as per radiology department for interven-tional ultrasound guided procedures. Costs for dailydressing for patients in the incision and drainage groupwas obtained from patient basing on how much she wascharged every time she would go for wound dressing atthe nearby clinic.

Data collection and statistical analysisData was collected using a structured and coded inter-viewer administered questionnaire. Administered in thequestionnaire were; Age, Parity, Social economic status,Smoking, Time of presentation from onset of symptomsand Size of breast abscess. Outcome variables included;Time to breast abscess resolution, Breast abscess recur-rence, Acceptance of ultrasound guided needle aspira-tion procedure and Cost of the procedures. Statisticalanalysis was done using SPSS computer software version11.5. Categorical data was summarized into proportions,percentages and rates. Continuous data was summarizedinto mean, median, mode, range and standard deviation.Tables were used to present data. Chi-square was usedto compare the differences between the two groupswhere the outcome was categorical and if continuous, t-

test was used. Statistical significance was defined as a Pvalue of less than 0.05. Survival Analysis using Kaplan-Meier and Cox Regression was used to compare thehealing rates between the two groups. For the cost data,costs in each intervention arm were summed up to givethe total expenditure per intervention. The cost effec-tiveness ratio was determined by dividing the total costof each intervention group by the number of patientssuccessfully treated.

Ethical issuesApproval to carry out research was obtained from;Faculty of Medicine Research Committee, NationalScience and Research Council, Mulago Hospital Com-plex and the department of surgery, Mulago hospitalbefore the commencement of the study.

ResultsA total of 71 patients with breast abscesses were seenduring the study period, of which 65 patients met theinclusion criteria and consented for the study. Sixpatients were excluded due to their abscesses beingalready draining pus and others having clinical featuresof immune suppression. Of the 65 patients, 33 patientswere randomized into Ultrasound guided needle aspira-tion group and 32 patients into incision and drainagegroup. During the follow up period, Ultrasound guidedaspiration had a success rate of 93.1% (27/33) singleaspiration, with 6.9% (2/33) re aspirated on the 1st visitdue to persistence of the abscess. There was no abscessconverted to I & D in the U.S guided needle aspirationgroup (Figures 1 &2).In both groups majority of patients were healed by the

3rd visit that is 65.5% (19) for Ultrasound guided aspira-tion group and 58.1% (18) for the Incision and drainage

Figure 1 A sonogram of a 22 yrs old female showing a rightbreast abscess. Note the oval shape of the abscess measuring 2.64cm by 1.54 cm before aspiration under U.S.S guidance.

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group. There was no difference in healing rate betweenthe two study arms at all the three visits (Table 1).Demographic characteristics, clinical presentation of

patients, size, shape and location of the abscess had noeffect on the healing rate between the two study groups(P > 0.001) (Table 2).

Survival analysisThe duration of healing for study group A was 24.24days and for group B was 24.16 days (Table 3). Theprobability of not healing was equal in the first week in

both study arms. In the second week, the probability ofnot healing was slightly higher in group A than B.While in the third week, the probability of not healingwas slightly higher in group B than A. Statistically thereis no difference in the probabilities of not healingbetween patients in group A and B (Log rank: 0.24, df 1P 0.63) (Figure 4). The Hazard rate of patients in ArmA was 0.93 times less the hazard rate of group B andthis was not statistically significant (P > 0.001) (Figure5).

Cost-effectiveness analysisThe number of patients effectively treated by Ultrasoundguided Needle aspiration (excluding loss to follow up)were 29 and for incision and drainage were 31 patients(Table 4). The cost effectiveness ratio for incision anddrainage arm was 2.85 times that of Ultrasound guidedneedle aspiration.

DiscussionThe breast is one of the sex organs of a female, in caseof breast disease care should be taken to insure that itsbeauty is minimally compromised in order to preserveits value and function. Despite of breast abscess becom-ing less in developed countries due to improved mater-nal hygiene, nutrition, standard of living and early useof antibiotics, breast abscess remain a problem amongwomen in developing countries [1].Treatment of breast abscess traditionally has been

incision and drainage however this has been found to beassociated with possible unsatisfactory cosmetic out-come, difficult in breast feeding and needs generalanesthesia, prolonged healing time, and regular dressing[3]. Repeated aspiration with or without ultrasound gui-dance has been found to be another treatment optionfor breast abscess and this has been reported to be asso-ciated with less recurrence, excellent cosmetic resultand has less costs [4-6,8].This study was conducted to establish whether ultra-

sound guided needle aspiration is a feasible alternativetreatment option for the breast abscess in Mulagohospital.This discussion is based on 65 patients with breast

abscesses randomized into 33 for Ultrasound guided

Figure 2 U.S.S guided needle aspiration of the Right breastabscess of the above patient. Note the needle in the breastabscess cavity during the aspiration process (see the arrows) Duringthe study period, no breast abscess recurrence was observed in theU.S aspiration group, and all the patient (100%) treated byUltrasound aspiration highly accepted the procedure (Figure 3).Incision and drainage group had a recurrence rate of 3.1% (1/32)during the follow up period. 5 (7.7%) women of the 65 were lost tofollow up, 4 patients were from the Ultrasound guided aspirationgroup and 1 patient from Incision and drainage group. Of the 4patients in the aspiration group, 2 missed the 2nd visit and theother 2 patients missed the 3rd visit. The patient in the Incision anddrainage group lost to follow up in the 3rd visit.

Figure 3 Right breast after U.S.S guided needle Aspiration ofthe Abscess of the above patient. Note the disappearance of theabscess cavity leaving behind inflamed tissues as indicated byarrows.

Table 1 Healing rates per group

Study group A B Oddsratio

95%CI P-value

Visit 1(Day 7) 3% (1) 9.4% (3) 0.30 0.03-3.07

0.29

Visit 2 (Day14)

29% (9) 21.9% (7) 1.46 0.47-4.58

0.51

Visit 3(Day 30) 65.5%(19)

58.1%(18)

1.37 0.48-3.91

0.55

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aspiration and 32 for incision and drainage intervention.The healing rate, recurrence, cost effectiveness werecompared between the two groups and acceptance ofUltrasound guided needle aspiration was assessed.Healing rate of the two groups had no statistically sig-

nificant difference both overall and at each visit (Logrank: 0.24 df 1 P-0.63), this was similar with what was

found elsewhere [4].This similarity in the healing ratebetween the two treatment option could be explained bythe fact that regardless of the way pus is removed fromthe cavity (that is incision and drainage, needle aspira-tion or spontaneous rupture onto the skin surface) thehealing process is the same which is by collapse of thecavity wall and adherence to one another by fibrin, later

Table 2 Mean Healing time of the two study arms at different variables

Variable Mean healing time in weeks Mean Difference 95%CI P-Value

US Aspiration I&D

Age in yrs

≤ 20 27.5 30.0 -2.46 -6.2-1.3 0.19

> 20 21.5 19.9 1.61 -4.8-8.1 0.61

Symptoms

≤ 7 days 20.6 22.0 -1.42 -11.8-8.9 0.77

> 7 days 28.7 24.0 4.70 -0.7-10.2 0.09

B/feeding

Yes 26.1 25.8 0.25 -4.9-5.3 0.92

No 22.5 15.8 6.70 -2.5-15.9 0.15

Parity

Primiparous 26.0 26.4 -0.45 -7.1-6.2 0.88

Multiparous 21.3 21.6 -0.35 -8.1-7.4 0.93

Nulliparous 24.7 30.0 -5.33 -28.3-17.6 0.58

Const.symp2

Yes 26.8 26.0 0.80 -8.4-9.9 0.83

No 23.7 22.9 0.80 -4.6-6.2 0.62

B/affected 3

Right 23.3 24.1 -0.73 -7.8-6.3 0.83

Left 24.9 23.3 1.55 -4.9-7.9 0.62

Q/affected 4

LUQ 5 23.6 20.3 3.26 -3.3-9.9 0.32

MUQ 6 18.0 27.3 -9.33 -19.9-1.3 0.08

LLQ 7 24.7 30.0 -5.33 -51.2-40 0.67

MLQ 8 25.7 31.0 -4.0 -49.2-39 0.62

SizeB/Absc 9

≤ 3 cm 15.3 13.5 1.74 -5.0-8.5 0.59

> 3 cm 27.1 30.0 -2.90 -5.93-0.11 0.06

Shape

Oval 22.0 30.0 -8.0 -18-3.0 0.11

Irregular 24.8 23.1 -3.7 -3.7-71 0.52

Multiloculated 24.6 14.0 10.7 -35.2-56 0.42

Location

Subareolar 17.5 25.4 -7.8 -20.2-4.5 0.18

Periphery 26.8 23.1 3.7 -1.2-8.6 0.14

Indeterminate 22.0 30.0 -8.0 -184-168 0.67

Table 3 Descriptive analysis

Study Arm Mean duration of survival (95% CI) Median duration of survival (95% CI)

A 24.24 (21.27-27.22) 30.00

B 24.16 (21.06-27.27) 30.00 (27.74-32.26)

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by granulation tissue. The remaining bacteria destroyedby polymorphs [9].There was no recurrence of breast abscesses observed

in the Ultrasound guided needle aspiration group duringthe study period. There was 3.1% (1/32) recurrence rateobserved in the incision and incision group. Howeverthis recurrence rate was far less than 31% recurrence inthe incision and drainage group which has beenreported in another study [8].This small recurrence rateobserved may have been resulted from a short follow upperiod and it was not possible to compare the recur-rence rate of the two study groups.All the patients treated with Ultrasound guided needle

aspiration highly accepted this modality (100%).This wasconsistence with what other studied found [8,10-12].

This high acceptance rate may have been resulted fromthe convenience of the procedure which was an outpati-ent one, having no wound to nurse and absence of scarafter healing.The cost effectiveness ratio of Ultrasound guided

aspiration was found to be much less than that of Inci-sion and Drainage, thus indicating that Ultrasoundguided aspiration provides savings to the hospital andthe patient, hence more cost effective than Incision andDrainage. This was consistence with what was foundelsewhere [11,13]. Since Ultrasound guided aspiration isan outpatient procedure as opposed to the Incision andDrainage which is inpatient procedure. Studies done tocompare outpatient versus inpatient surgical proceduresshowed that outpatient procedures were cost effective[14,15].

ConclusionThere is no difference in terms of healing rate of breastabscess between Ultrasound guided aspiration and surgi-cal incision and drainage, Ultrasound guided needleaspiration is highly accepted by women with breastabscesses in Mulago hospital. Ultrasound guided aspira-tion is more cost effective than Incision and Drainage inmanagement of breast abscess, therefore Ultrasound

0.00 5.00 10.00 15.00 20.00 25.00 30.00

Duration of healing in days

0.0

0.2

0.4

0.6

0.8

1.0

Cum

Survi

val

study armstudy arm Astudy arm Bstudy arm A-censoredstudy arm B-censored

Survival Functions

Figure 4 Survival Function.

0.00 5.00 10.00 15.00 20.00 25.00 30.00

Duration of healing in days

0.0

0.5

1.0

1.5

2.0

2.5

3.0

Cum

Haz

ard

study armstudy arm Astudy arm Bstudy arm A-censoredstudy arm B-censored

Hazard Function

Hazard Ratio (HR)

HR 0.93 95% CI 0.56-1.56

X2 0.071 df 1 P 0.79 Figure 5 Hazard Function.

Table 4 Cost-Effectiveness analysis

Category Intervention

U.S. Guided Needleaspiration

Incision &Drainage

Admission 620000

Professional fee 2900000 3100000

Preoperative fee 620000

Surgery fee 6100000

Anesthetic fee 3200000

Amenities 580000 620000

Sundries 290000 310000

Lodging 930000

Intervention U.S.S 870000

Cannula (FG 16) 43500

Syringe 20cc 29000

Drugs 246500 259600

Dr. in charge carefee

290000 310000

Health care fee 290000 310000

Wound dressingcost

489500

Total 5539000 16869100

Number ofpatients

29 31

Cost-effectivenessratio

191000 544164.5

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guided needle aspiration is an effective treatment optionfor both lactating and non lactating breast abscess.

AcknowledgementsThe authors are grateful to all those who were involved in the care of thestudy patients. Special thanks go to all the members of staff of SurgicalDepartment, Makerere University, for their stimulating criticisms andcontributions they made in the preparation of this manuscript.

Author details1Department of Surgery, Weil Bugando University College of Health Sciences,Mwanza, Tanzania. 2Department of Surgery, Makerere University Kampala,Kampala, Uganda. 3Department of Radiology, Makerere University Kampala,Kampala, Uganda.

Authors’ contributionsABC conceived and designed the study and did the literature search,coordinated the write-up, editing and submission of the article. AMG & KEMcoordinated the write-up, editing and supervised the study. PLC participatedin the literature search, writing of the manuscript and editing. All theauthors read and approved the final manuscript.

Competing interestsThe authors declare that they have no competing interests.

Received: 6 July 2011 Accepted: 6 January 2012Published: 6 January 2012

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doi:10.1186/1756-0500-5-12Cite this article as: Chandika et al.: Ultrasound Guided Needle Aspirationversus Surgical Drainage in the management of breast abscesses: aUgandan experience. BMC Research Notes 2012 5:12.

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